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7726 Finns Lane, Suite LL2
Lanham, MD 20706
Ph: (202) 409-6564
Fax: (240) 770-3161
 

Enrollment Form Nursing Assistant Program

To fax: Print and fax to  (240) 770 -3161
Or click here to download, enrollment form in PDF format complete and e-mail to dominonacademy@hotmail.com or fax to number above. You will need Adobe Reader to download this file, you you don’t have it. Click here.
 

SS # or Alien Number(If applies)	Date of Birth:
Date of Application:	First Name(Legal):
Last Name (legal):		Maiden Name (if different):
Sex :	Male	Female	Race:
Permanent Address

Home Number:	Work Number:	Name of Current Employer:	Employer’s Current Address:
Education
I have graduated high school:	Graduation Year:	High School Name:	City / State:
No:       Yes:
I have a GED:	Year Recieved:	Name of School/ Test Center:	City/State:
No:              Yes:

Enrollment Information:

  Start Date:       Projected Graduation Date
Program Information: Nursing Assistant Program, 120 clock hours, Day Program: 4 Weeks, 30 hours per week, 6 hours per day (includes lunch), Monday through Friday and Evening Program: Lecture Monday – Friday   Five (5) days/week for 4.8 weeks & 5 hours/day Evening Section Variations: two (2) laboratory days will end an hour early and four (4) clinical days will be ½ hour longer.

Schedule: (select one)   8:30 a.m. to    2:30 p.m.     OR       3:30 p.m.  to  10:00 p.m.

The cost of the program is: 

Registration Fee:                          $ 80.00 (included in tuition)
Tuition                                        $ 820.00
First Day of Class                       $ 410.00
Weekly/Bi-Weekly Payment       $ 205 x 2 payments
Skills Kit                                     $ 100.00
 Text Book                                 $ 120.00

Make registration payment now     

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Billing Address
 

Name
Address
City		State
Country		Zip
Email

Billing Information

Credit card
Name on Card
Card number
Expiration

Before Submitting, click here to read our program policy.